"Every error counts": a web-based incident reporting and learning system for general practice

Abstract

Background: Incident reporting systems have been established primarily in the inpatient setting. Their goal is the identification of safety risks in healthcare as a precondition for improvements in the overall quality of care. Knowledge about medical errors in general practice is sparse, as are reporting systems for patient safety in this setting. This article describes the development, structure and initial results of an incident reporting system for general practices in German-speaking countries.

Methods: Jeder Fehler Zaehlt (JFZ; www.jeder-fehler-zaehlt.de) is a web-based reporting system that receives incident reports from anonymous German-speaking users. Reports are fed into a database, classified and analysed by a team of experts. Exemplary reports are published on the internet and in journals, and the reporting system provides the opportunity for users to comment on and learn from these incidents.

Results: The incident reporting system received 199 reports in the 17 months following its launch, of which 188 were classifiable. Of these, 72.9% were classified as process errors and 26.1% as knowledge/skills errors. The most frequently reported process errors were treatment errors (32.2%), communication errors (12.6%) and investigation errors (8.5%). Of the classified errors, 41.5% were associated with harm to the patient. More than 300 comments were made, mostly by anonymous users of the system.

Conclusions: JFZ is a well-functioning and growing incident reporting system. Future efforts to improve the benefits of incident reporting will concentrate on increasing the utilisation of the system and broadening the spectrum of reported incidents.